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What’s the Big Deal about Vitamin D?. Rebecca B. Saenz, MD, IBCLC, FABM Mississippi Breastfeeding Medicine Clinic, PLLC Madison, Mississippi. In the news. And on the Web. What is Vitamin D?. Actually, a hormone Receptors in many organ systems –

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what s the big deal about vitamin d

What’s theBig Deal about Vitamin D?

Rebecca B. Saenz, MD, IBCLC, FABM

Mississippi Breastfeeding Medicine Clinic, PLLC

Madison, Mississippi

slide2

In the news

And on the Web

what is vitamin d
What is Vitamin D?

Actually, a hormone

Receptors in many organ systems –

Bone, skeletal muscle, brain, prostate, breast, colon, pancreas, immune cells

Vitamin D2 = calciferol – about 30% activity of D3

Vitamin D3 = cholecalciferol

vitamin d synthesis
Vitamin D synthesis

Vit D from skin or diet >

Metab in liver to 25-OH-Vit D >

Metab in kidneys to 1,25-diOH-Vitamin D3

Regulated by parathyroid hormone and serum calcium and phosphorus

Excess 25-OH-Vit D and 1,25-diOH-Vit D are catabolized into inactive calcitroic acid and excreted in bile

what vitamin d does
What Vitamin D does--

Increases calcium and phosphorus absorption

Enhances bone mineral density

Increases insulin production in pancreas

Decreases renin production in kidneys

Immunomodulatory

Anti-inflammatory

Role in preventing genetic expression of some cancers (local effect)

disease states
Disease States

Skeletal – rickets, osteopenia, osteoporosis, osteomalacia, fracture

Muscular– weakness, twitches

Skin -- psoriasis

Cardiac – hypertension, CHF, inc. CRP

Pulmonary – wheezing illnesses

Immune – diabetes, MS, Crohn’s, RA, OA

Psychiatric – schizophrenia, depression

Other – prostate, colon, & breast cancers, and non-Hodgkins lymphoma

vitamin d levels
Vitamin D levels

(measured as serum 25-OH-Vit D levels)

Deficiency < 20ng/ml

Insufficiency = 21-29ng/ml

Sufficiency >30ng/ml

Preferred range = 30-60ng/ml

Intoxication >150ng/ml

sources of vitamin d
Sources of Vitamin D

Sunshine – ultraviolet B radiation (290-315nm)

0.5 “minimal erythemal dose”* gives

about 3000IU of vitamin D3

*0.5 minimal erythemal dose =

about 5-10** minutes of exposure

of arms and legs to direct sunshine,

**Depending on time of day, season, cloud

cover, extent of air pollution, latitude, body

mass, amount of exposed skin, UVB protection,

and skin sensitivity (complexion & genetics)

a word about sunshine
A word about sunshine . . .

It’s GOOD in moderation!

10-15 minutes daily

Short sleeves and pants

Without hat or sunscreen

SPF 15 or higher blocks 99% of UVB

What about risk of skin cancer?

Apply sunscreen after those first 10-15 minutes!

slide10

“It is virtually impossible to get enough sunshine from November to Februaryabove 35 degrees latitude*to stay “sufficient”.

*35 degrees latitude is the north border of Georgia, Alabama, and Mississippi, and cuts Arkansas in half just north of Little Rock

sources of vitamin d11
Sources of Vitamin D

Dietary (Adults)

Salmon 100-1000 IU

Sardines 300 IU

Mackerel 250 IU

Tuna 230 IU

Cod liver oil 400-1000 IU

Shitake mushrooms 100-1600 IU

Egg yolk 20 IU

sources of vitamin d12
Sources of Vitamin D

Dietary (“Fortified”)

Milk, OJ, yogurt, 100 IU/8oz

Infant formula 100 IU/8oz

Butter 50 IU/3.5oz

Margarine 430 IU/3.5oz

Cheeses 100 IU/3oz

Breakfast cereals 100 IU/serving

sources of vitamin d13
Sources of Vitamin D

Dietary Supplements

Prescription

Vitamin D2 (ergocalciferol) 50,000IU/cap

Drisdol liquid vit D2 8,000IU/ml

Over the Counter

Multivitamin / Prenatal 400IU

Vitamin D3 400, 800, 1000, or 2000 IU

Infant drops 400IU/dose

sources of vitamin d14
Sources of Vitamin D

Dietary (Infants)

Human Breast Milk Vitamin D content varies based on Mom’s Vitamin D status,

which varies based on her

sunlight exposure and dietary intake.

Range: 5-20 IU / liter, if mom unsupplemented

Up to >800 IU / liter if mom on high-dose Vit D

slide15

DATE: August 29, 2008

It is clear that vitamin D content of human milk is variable and directly related to maternal vitamin D status. Human milk is not deficient in vitamin D per se; rather, it is deficient in vitamin D when mother is deficient. Vitamin D transfer into mothers’ milk is predictable: a deficient woman has little to transfer to her infant via her milk; if her status improves, transfer of vitamin D in her milk to the baby will also. Maternal vitamin D deficiency and resultant nutritional rickets in her nursing infant is preventable: supplementation of the infant with vitamin D will ameliorate deficiency in that age group, but does not address maternal needs. Adverse effects associated with vitamin D deficiency affect bone development and innate immunity such that no woman and her baby should be deficient. We must prescribe a safe intervention that will achieve sufficiency in both mother and infant and not blame human milk as the culprit, but rather, see the problem as the larger public health issue that it is.

Caroline Chantry, MD Karla Shepard Rubinger

President Executive Director

Academy of Breastfeeding Medicine Academy of Breastfeeding Medicine

140 Huguenot Street, 3rd floor

New Rochelle, NY 10801-5215

risk factors for vit d deficiency
Risk Factors for Vit D Deficiency
  • Reduced skin synth
    • Sunscreen
    • Pigment
    • Aging
    • Season/latitude/time
    • Skin grafts
  • Dec. bioavailability
    • Malabsorption
      • Cystic fibrosis
      • Celiac disease
      • Crohn’s disease
      • Gastric Bypass surgery
      • Cholesterol lowering meds
    • Obesity
risk factors for vit d deficiency18
Risk Factors for Vit D Deficiency
  • Increased catabolism
    • Anticonvulsants
    • Glucocorticoids
    • Others
  • Increased urinary loss of 25-OH-D
    • Nephrotic syndrome
  • Decreased synthesis of 25-OH-D
    • Liver failure
  • Decreased synthesis of 1,25-diOH-D
    • Chronic kidney disease
risk factors for vit d deficiency19
Risk Factors for Vit D Deficiency
  • Heritable Disorders – (Rickets)
    • Vit D dependent rickets – type 1
    • Vit D resistant rickets
    • Vit D dependent rickets – type 3
    • AD hypophosatemic rickets
    • X-linked hypophosphatemic rickets
  • Acquired disorders
    • Tumor-induced osteomalacia
    • Primary hyperparathyroidism
    • Granulomatous disorders (sarcoid, TB)
    • Hyperthyroidism
risk factors for vit d deficiency in infants
Risk Factors for Vit D deficiency in infants
  • Mom who is “insufficient” or “deficient” during pregnancy or lactation
  • Baby is both exclusively breastfed
  • AND sheltered / protected from sunlight.
    • Babies born in fall/winter
    • Babies in full-time daycare
    • Living above 35 degrees N latitude
  • Babies born prematurely
recommendations breastfeeding babies
Recommendations – Breastfeeding Babies

Vitamin D2 suppl is approx 30% as effective as vit D3 suppl – calculate accordingly!

AAP: 400 IU vitamin D3 / day

Sensible sun exposure

1000-2000 IU vitamin D3 / day is safe, if necessary to treat deficiency

slide22

Supplementation of the nursing infant with oral vitamin D . . . does not address the issue of why the antirachitic activity of the mother’s milk is low --- namely, that her vitamin D status is poor.

Wagner CL, Taylor SN, and Hollis BW. Does Vitamin D Make the World Go ‘Round? Breastfeeding Medicine 2008; 3(4):239-250.

correlation of maternal and infant 25 oh vit d levels

Maternal Infant Maternal Infant

Vit D Vit D serum serum

Suppl Suppl 25(OH)D 25(OH)D

2000IU/day 0 36.1 27.8

4000IU/day 0 44.5 30.8

6400IU/day 0 58.8 46

400IU/day 300IU/day 38.4 43

From: Hollis BW, Wagner CL. Vitamin D requirements during lactation: high-dose maternal supplementation as therapy to prevent hypovitaminosis D for both the mother and the nursing infant. Am J Clin Nutr 2004; 80:Suppl 6:1752S-1758S.

Wagner C, Hulsey TC, Fanning D, et al. 2006. High-dose vitamin D3 supplementation in a cohort of breastfeeding mothers and their infants: a six-month follow-up pilot study. Breastfeeding Medicine 1(2):59-70.

Correlation of Maternal and Infant 25-OH-Vit D levels
slide24

“We understand more fully now that this deficiency is not caused by something that is inherently wrong or missing in mother’s milk but rather by inadequate maternal dietary vitamin D intake and the resultant low concentrations in the mother’s milk.”

Wagner CL, Taylor SN, and Hollis BW. Does Vitamin D Make the World Go ‘Round? Breastfeeding Medicine 2008; 3(4):239-250.

supplementation of breastfeeding mothers
Supplementation of Breastfeeding Mothers

“Lactating women given 4000 IU of vitamin D3 per day not only had an increase in the level of 25-OH vitamin D to more than 30 ng/ml, but were able to transfer enough vitamin D3 into their milk to satisfy an infant’s requirement.”

Hollis BW, Wagner CL. Vitamin D requirements during lactation: high-dose maternal supplementation as therapy to prevent hypovitaminosis D for both the mother and the nursing infant.

Am J Clin Nutr 2004; 80:Suppl 6:1752S-1758S.

recommendations lactating mothers
“Recommendations” – Lactating Mothers

Vitamin D2 suppl is approx 30% as effective as vit D3 suppl – calculate accordingly!

1000 – 4000 IU vitamin D3 / day

50,000 IU vitamin D2 q 2 weeks to treat deficiency

Up to 4000 IU vitamin D3/day is safe for 5 mos

Up to 6400 IU / day has been used for 3 months without problems.

summary
Summary
  • Vitamin D deficiency is much more widespread than previously thought
  • Vitamin D deficiency is a factor in many diseases, not only rickets and osteoporosis.
  • Modern life is deficient in sunshine, and thus in vitamin D.
  • Some form of vitamin D supplementation may be appropriate for many breastfeeding mothers / babies.
summary28
Summary
  • “In the future, we expect that by treating the mother with a sufficient dose of vitamin D, both mother and her recipient infant will achieve normal vitamin D status.”
  • Wagner CL, Taylor SN, and Hollis BW. Does Vitamin D Make the World Go ‘Round? Breastfeeding Medicine 2008; 3(4):239-250.
mississippi breastfeeding medicine clinic pllc
Mississippi Breastfeeding Medicine Clinic, PLLC

Rebecca B. Saenz,

MD, IBCLC, FABM

111-A Depot Drive

Madison, MS 39110

601-898-7979

Fax 601-898-7989

drbecky@msbfmedclinic.com

And on Facebook!